From Kindergarden to Death & Taxes

If you've followed this blog at all, you may now appreciate that August is neigh and in Nepali terms, that doesn't mean the end of summer vacation, start thinking about closing down the pool or that you should write your congressman about the importance of balancing the budget.  It means there's less than 30 days before the new constitution is due from the incumbent Maoist party.  Now I know, we've heard it all before, much like the looming deadlines facing the USA on the federal debt ceiling crisis, Nepal is struggling to pull together its various political factions in order to establish a new constitution.  August 30th marks yet another extension deadline that was set on 30 May.  And since the new deadline was set, things in Kathmandu have been relatively calm - no serious protests, no bandhs (strikes) and few public threats against public officials.  There is, however, another type of upheaval going on - we call it political jockeying.

It's no secret that Nepal is comprised of a variety of political parties and that the country is made up of people who come from various castes - much like you learned about in your 4th grade geography class, these castes establish the worth of the people and their proverbial lot in life.  The GESI component of the reform project that I am working on is dedicated to improving Gender Equality and Social Inclusion and intends to minimize the attention that is given to the caste system, yet the concept of individual value consumes considerable share of mind among the Nepali people.  Little wonder, therefore, that the government is equally obsessed with social structure and caste. (What came first, the chicken or the egg?)
In an effort to satisfy the various political factions within the country, leadership has embraced the childhood game of Musical Chairs (and although Nepal has already elevated other childhood games such as Chicken, the Hoki-Poki and Shoots & Ladders to national pastimes, it's latest obsession with the kindergarten game of Musical Chairs seems to have consumed the attention of Nepal's government officials).  
Since our team began its work on healthcare reform last October, there have been dozens of changes of high level government officials at the whim of the national leadership.  When one group is dissatisfied that the Minister of the Interior is not of a particular cast or party affiliation, a change is made and a new minister is appointed.  When, after months without a Minister of Health, a high cast Chettra is appointed, we learn that he has been replaced.  This is very unfortunate given that the recent Health Minister was engaged enough to admonish the Secretary of Health for her excessive travel schedule to luxury destinations while coyly evading critical duties such as signing contracts for NGOs who deliver critical healthcare services and completing the national healthcare budget.  Finally, it felt as if we were moving in the right direction....until 10 days ago when news broke in the Himalayan Times that the Health Minister (along with other officialss) was replaced by someone of a 'lower caste'.  No real explanation was made as to why this was so important after the new Minister was less than 60 days in the job.
Musical Chairs has become a government obsession and a real distraction for Nepal's leaders.  As new Ministers and division heads are appointed, (and I can speak from experience with my current government counterpart,) they almost seem paralyzed with fear to make decisions.  If s/he cannot satisfy one of his/her 'masters', it is possible that his/her service will be short lived and a replacement will be found.  And what do leaders do when they are afraid to make a decision? They go AWOL.  That's right, they hide, become evasive, defer, delay and obfuscate reality.  It's an interesting game of cat and mouse where no one wins and the cheese gets stale before anyone gets to taste it.
I received an interesting book from my section head that was intended to help me acclimate to the Nepali culture.  Please indulge me as I share a brief segment with you that I found truly enlightening on the Nepali mindset.  The source, a book titled, "Fatalism and Development" written by Dor Bahadur Bista, includes a passage that speaks about Achievement Motivation in Nepal;
         "As a career objective in modern Nepal, every Nepali tries to have a Jagir, 
          a salaried job where one does not have to work but will receive a pay cheque
          at the end of each month.  Candidates still show their zeal and enthusiasm for 
          work at the time of applying for the job, because that is the rule one has to follow.  
          But in such jobs one is not expected to actually work."  
Regrettably, this seems to reveal some fatalistic realities that undermine societal advancement in this country.  Reading it was an 'a-ha' moment for me and something I began to suspect when I would observe staff members sitting at clean desks with blank looks upon their faces when asked to attend to a task that had been assigned for completion days prior.
The fatalistic attitude that seems to penetrate the lives and minds of the Nepali people is perhaps the only reason that we have not yet seen the violent uprisings that have been observed in Tunisia, Libya, Egypt and elsewhere throughout the Middle East and North Africa.  Will such uprisings occur at the end of August? We'll have to wait and see, but the rumors flying about more changes to government posts within the healthcare ministry are paralyzing its leadership and delaying the critical change that is needed in order to meet the deadlines and objectives of this program as well as for the country to further benefit from the generosity of various donor organizations.
And as the life of a government employee goes, so too does the life and death of a Nepali citizen.  Last week I took the opportunity to visit Pashupatinath with my wife who came to see first hand what life in Nepal is really like.  Pashupatinath is Nepal's most important Hindu temple located along the banks of the Bagmati River.  Many choose to be cremated here in a ceremony that is  steeped in custom, ritual and tradition.  Even in death, castes are separated by a bridge.  Lower castes can cremate their dead on the lower side of the bridge, while higher castes and royalty can conduct their cremation ceremony along the upper banks of the river on the other side of the bridge.  The dead are prepared by cleansing their bodies in the river and then laid on the pier and in a combination of ritual and custom, they are fed fire to begin the cremation - as life (like death) is taken in the mouth.  The burning of bodies and prayers as well as other sacrifices ensures that the Gods will receive them and that the dead will receive the intended blessings as provided by friends and family in the tradition of a burning sacrifice.
While it's been said that the only certainties are death and taxes, in Nepal we can only hope to add change to that list.

Demands of the Job

Every day is an adventure.  It's not always the kind of adventure we are hoping for or the kind of adventure we were anticipating.  But we learn a lot along the way and try to steer the ship despite the ever shifting current and the occasional tsunami.
If you've ever been a part of international development programs - often called "projects",  you know how they work....donor organizations make contributions with the expectation that the teams they appoint to do the work will make them proud and create a story that allows them to promote (if not merely share) the outcome of their generosity.  This is a wonderful thing when it works well.  Such "Projects", however, have become known as sources of 'easy money' to government officials in 3rd world countries - not because the administrators hand out gobs of cash, but because the projects themselves are able to allocate funds as they deem appropriate - buying vehicles, hiring support staff for government officials and paying for trips under the guise of 'capacity enhancement' (aka training and education).  One such project, I have learned has paid for my government counterpart's education at Johns Hopkins University - (and, yes, I too would like to have ridden that train!)
Nonetheless, I share this with you only because I want to differentiate the kind of work that I am engaged with from a "project".  We are a team of government advisors.  Our role is to develop plans that aim to put the healthcare system on a path toward increased access, improved quality and affordability.  We collaborate with the government to devise these plans, although sometimes (more often than not) we generate the ideas, plans and do the analysis to justify the recommendations and then work to gain the support of the government in moving forward.  It's a seemingly noble, lofty and daunting initiative that we signed up for with the intention of working collaboratively with government, EDPs (External Development Partners, aka donors), NGOs and a variety of other stakeholders depending on one's area of focus - in my case; suppliers, regional and community healthcare leaders and other members of the Nepal medical and drug supply chain.
As mentioned earlier, donors are well intentioned, and their intentions are as formidable as they are well-directed.  This, of course, presumes that they are directed at all.  You need only walk the streets of Kathmandu to realize just how many NGOs have penetrated Nepal - each with the goal of providing a service or program that is intended to improve some aspect of the lives of the people of Nepal - be it their roads, water supply, energy, education or healthcare delivery.  Strangely, but not surprisingly, there is no regulation or true coordination of such activities.  This creates a problem for anyone trying to see what is truly going on here.  Here's an example;

As we all know, HIV/AIDS is a pandemic which spans the globe - some countries hit harder than others and none have had it as hard as South Africa.  Fortunately for Nepal, HIV/AIDS affects less than 1% of the population of the country, but unless managed carefully, the downward trend, resulting from a strong supply of ARVs (drugs to manage the disease) and other commodities for infections, could quickly reverse and spiral out of control.
Over the last month, Nepal has been teetering on the edge of disaster with respect to the mismanagement of supply to the population struggling with this disease.  How can this happen? Glad you asked (but in a minute you may not be).  In most countries, there is an established body known as the CCM or country coordinating mechanism.  This body is tasked with coordinating the efforts of the many NGOs (non-government organizations) - that work to fill the void in services that the government cannot provide due to lack of funds, personnel, skills, etc.  They can also help to identify areas of risk prior to outbreaks of disease, famine, conflict, etc and then marshal the resources where they are needed.

In Nepal, the CCM responsible for coordination of HIV/AIDS commodities seems to have had a lapse in control and consequently the supply of the drugs and service providers for people living with HIV/AIDS are on the verge of being interrupted.  For an AIDS patient, this can be devastating.  Even a brief interruption of essential medicines to manage this disease can result in new strains of the disease that cannot be managed by conventional drugs, necessitating the development of new clinical cocktails and much experimentation.  It is a truly precarious and difficult situation.
To address this situation, the Global Fund has agreed to provide an uninterrupted supply of HIV/AIDS products to Nepal.  But before they do, they are asking that we define and implement the logistics and supply chain that will ensure for quality control and efficient distribution of these items.  This is an essential component of my work here - and they want to see this achieved over a remarkably compressed time frame.
Without boring you with the details, this equates to much more than sweating the small stuff.  This will be an all out race to the finish.  Deep breath! More later.